2. First Name*
3. Last Name*
4. Date of Birth*
   Format: mm/dd/yyyy
6. Address*
7. City*
9. State*
10. Zip Code*
11. Email Address
13. Phone Number*
14. Business Number
15. Fax Number
17. Poitical Party Affiliation*
    Statutorily required for some boards.
18. Gender*

    1. Female
    2. Male
20. Have you ever been convicted of a felony?*

    1. Yes
    2. No
21. Please Explain
22. Education Level*
    -- Select One --No schooling completedPre-School to 8th gradeSome high school, no diplomaHigh school graduate, diploma or GEDTrade/technical/vocational trainingAssociate degreeBachelor’s degreeMaster’s degreeProfessional degreeDoctorate Degree

    What is the highest degree or level of school you have completed? If currently enrolled, highest degree received.
24. Board/Commission or Area of Interest:*

    1. 911 Service Fee Appeals Board
    2. Airport Board-Voting Members
    3. Aviation Noise Abatement Committee
    4. Board of Adjustments
    5. Board of Assessment Appeals
    6. Building Appeals Board
    7. Convention Center Corporation Board
    8. County Extension District Board
    9. Elsmere Fire Protection District
    10. Emergency Communications Board
    11. Ethics Commission
    12. Independence Fire District Board
    13. Joint Code Enforcement Board
    14. Kenton Conservancy Board

    1. Kenton County Conservation District
    2. Kenton Fire Protection District
    3. Kenton-Covington Wellness Center Board
    4. Local Board of Health
    5. Library Board of Trustees
    6. Historic Linden Grove Cemetery & Arboretum
    7. MeetNKY
    8. Northern Kentucky Area Planning Council
    9. NKADD Board of Directors
    10. NKADD Council on Aging
    11. NKIDHD Board of Health
    12. Northern Kentucky Community Action Commission
    13. OKI

    1. Parks & Recreation Commission
    2. Piner - Fiskburg Fire Protection District
    3. Planning Commission
    4. Police Merit Board
    5. Port Authority
    6. Regional Communication System Board
    7. Road Closure Committee
    8. Ryland Heights Fire Protection District
    9. Sanitation District Number 1
    10. South Kenton County Working Group
    11. Telecommunications Board of Northern Kentucky
    12. Transit Authority of Northern Kentucky
    13. Water Service District
26. Professional Certifications
28. Community Involvement
    Please describe.
30. Acknowledgements
    I acknowledge upon submitting this application that the County Judge reserves the right of appointment to boards and commissions and that under normal circumstances, board membership shall be limited to two (2) consecutive terms or eight (8) years of service on a particular board or commission. I also acknowledge that I am expected to attend a minimum of 75% of the meetings held by the board or commission to which an appointment is made and that the failure to do so, without specific medical necessity will result in my having forfeited said position.
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field